Examination of a joint an OSCE guide

1. Expose the Joint and the muscles acting on It.
2. Observe and note any deformity, swelling or muscle atrophy.
3. Palpate the Joint for synovial thickening, warmth, points of tenderness and any abnormal masses.
4. Elicit fluid thrill if swelling is present.
5.  Assess passive and active range of Joint movement.
6. Palpate during movement to elicit Joint crepitus.
7. Test the ligaments that stabilise the Joint.
8. Compare the two sides.

Note

Fluid thrill indicates effusion while a 'boggy feel" without a fluid thrill indicates synovial thickening. At times both may be present.

This is important for those students preparing for USMLE and MRCP

Examination of Subcutaneous Nodule or Swelling an OSCE guide

Elicit History

Duration, mode of onset, progression, assoeiutcd pain and

treatment—history.

Inspection

Number, site, shape, colour, surface, edge, pulsation.

Impulse on coughing and skin over the swelling.

Palpation

a. Local rise of temperature, tenderness, size, shape, surface, edge or margin, consistency.

b. Fluctuation, translucency. reducibility.

c. Impulse on coughing, mobility, anatomical plane and fixity, pulsation and thrills.

Percussion or Auscultation

In relevant cases.

Regional Examination

For lymph nodes, muscle wasting, bony erosion, sensory deficits and absence of pulse.

Comment on—probable diagnosis/aetiology.

These steps are very important for students preparing for USMLE and MRCP

How to conduct thyroid examination an OSCE guide

Local Examination

1. Expose the neck adequately.

2. Ensure adequate lighting.

Inspection

Comment on position, size, shape, surface, pulsations.

overlying skin and movement on deglutition and protrusion of the tongue.

Neck Measurements

Measure the circumference of the neck at the most prominent part of the swelling.

Palpation

• Patient's neck is slightly flexed (to relax muscles).
• Examine from the front or from behind the patient.
• Otto's method: Place the thumb and fingers on the thyroid. Palpate the thyroid when the patient swallows.
• Lahey's method -Push the thyroid to one side Palpate the lobe on the side which becomes prominent.

Comment on position, size. shape, surface, consistency (uniform, variable, cystic, solid, firm. hard), mobility (Hortzontal and vertical), tenderness and on the рутаmidal lobe If present

Auscultation

For thyroid bruit

Others

1. Carotid pulse. Present or absent on each side.

2. Horner's syndrome.

3. Kocher's test: Press the lateral lobes of the thyroid (stridor occurs In compressed trachea).

4. Lymph nodes for secondaries.

 General Examination

1. Relevant examination to elicit-symptoms and signs of hyper or hypothyroidism.

2. Eye signs.

Additional examination

a. Tongue: For any lingual thyroid.

b. Pemberton's sign: flic patient raises both his/her arms until they touch the ears. Hold up for some

time. Congestion of the face, cyanosis and distress occur In a retrosternal goitre.

How to elicit the eye signs of thyroid disease an OSCE guide

Following are the important eye sign in thyroid disease.

1.Exophthalmos: Unilateral or bilateral.

Comment on the widened palpebral fissure, visibility of the sclera above and below the limbus.

2. Von Graefe's sign:

3. Stellwag's sign Observe for retraction of upper eyelid and Infrequent blinking.

4.Joffroy's sign

5.Moebles sign: Look for Inability to converge the eyes.

What is Rocker Bottom Feet ?

This is a severe type of flat foot with a protuberant heel.

It is characterised by a prominent calcaneus/heel and a convex rounded sole.
It has Persian slipper appearance

• Calcaneus in fixed equinus
• Achilles tendon is very tight
• The hindfoot is in valgus
• The head of the talus is found medially in the sole
• The forefoot is abducted and dorsiflexed.

It is also known as a congenital vertical talus
What is the pathology of Rocker bottom feet?
It occur from a dorsal and lateral dislocation of the talonavicular joint.
Seen in the following conditions
Aneuploidic syndromic

• Trisomy 13- Patau syndrome
• Trisomy 18 also called Edward's syndrome, which may be associated with PDA
• 18q deletion syndrome

Non-aneuploidicsyndrome

• Spina bifida
• Arthrogryposis

What are the differential diagnosis ?
In the antenatal/neonatal period clubfoot is an important differential diagnosis
In the adult period differentail diagnosis considered is acquired rocker bottom deformity occurring secondary to:
Underlying neuromuscular disorder

diabetic foot (Charcot joint)

Causes of absent tendon reflexes:

Tendon reflex may be absent in the following situations

• Lower motor neurone disease
• Neuronal shock
• Marked spasticity and muscle contracture
• Normal individuals unable to relax

It is  seen in lower motor neuron lesions involving  any part of the reflex arc

• Lesion of the sensory nerve (polyneuritis)
• Lesion of the sensory root (tabes dorsalis)
• Lesion of the anterior horn cell (poliomyelitis)
• Lesion of the anterior root (compression)
• Lesion of the peripheral motor nerve (trauma, polyneuritis).

Before labelling as absent reflex do reinforcement
Reinforcement

What are the common causes of Hyporeflexia?

Hyporeflexia is a condition characterized by the absence or diminished reflex in reaction to an applied stimulus. This condition is associated with the lower motor neuron disease defined by a deficit in the nerve that runs through the spinal cord going to the extremities.
Hyporeflexia is the hallmark of LMN lesion .It is also seen in UMN shock
LMN lesions

• AHC
• Root
• plexus
• nerve
• muscle
• Neurological shock
• Severe extrapyramidal rigidity
• Contracture

• Peripheral neuropathy
• GBS
• SACD
• Tabes dorsalis
• Friedreich's ataxia
• Periodic paralysis
• Cerebral or spinal shock

Isolated loss of a rellex usually suggests radiculopathy.
Symmetrical loss of rellex may be found in peripheral neuropathy.
Reflexes may be absent if the patient is unable to relax.
A reflex seems lost or diminished in defect of technique, relaxation, or observation.

Technique of elicitation of deeptendon reflex

In a screening examination you it more convenient to integrate the reflex examination into the rest of the examination of that part of the body; that is, do the lower extremity reflexes when examining the rest of the lower extremity. When there is an abnormality of the reflexes is noted , however, the reflexes should be examined as a group with careful attention given to the technique of the examination.
Reliable test results are best obtained when the patient is fully relaxed
Explain the procedure to the patient

• If you fails to get any response with a specific reflex that can usually occcur with ankle jerks then try the following:
• Several different positions of the limb.
• Get the patient to put slight tension on the muscle being tested. One method of achieving this is to have the patient strongly contract a muscle not being tested.
• In the upper extremity, have the patient make a fist with one hand while the opposite extremity is being tested.
• If the reflex being tested is the knee jerk or ankle jerk, have the patient perform the "Jendrassik maneuver," a reinforcement of the reflex . The patient's fingers of each hand are hooked together so each arm can forcefully pull against the other. The split second before you are ready to tap the tendon, say "pull."
• In general, any way to distract the patient from what you are doing will enhance the chances of obtaining the reflex. you can instruct the patient to count or give the names of children are examples.

The best position to elicit reflex is that the patient to be sitting on the side of the bed or examining table. The Babinski reflex hammer may be used..

• Use a brisk but not painful tap. 
• Use your wrist, not your arm, for the action. 
• In an extremity a useful maneuver is to elicit the reflex from several different positions, rapidly shifting the limb and performing the test. Use varying force and note any variance in response.
• After obtaining the reflex on one side, always go immediately to the opposite side for the same reflex so that you can compare them.

You should note the following features of the reflex response:

• Amount of hammer force necessary to obtain contraction
• Velocity of contraction
• Strength of contraction
• Duration of contraction
• Duration of relaxation phase
• Response of other muscles that were not tested. When a reflex is hyperactive, that muscle often will respond to theexamination of a nearby muscle. A good example is reflex activity of a hyperactive biceps or finger reflex when the brachioradialis tendon is tapped. It is termed "overflowing" of a reflex.